Deceased
Dorothy Anne Simm
Demographics
74y, female
Coroner
Coroner Audrey Jamieson
Date of death
2023-04-26
Finding date
2026-01-23
Cause of death
Non traumatic intracerebral haemorrhage with further deterioration post medical intervention
AI-generated summary
Dorothy Simm, a 74-year-old woman, died from intracerebral haemorrhage with post-operative deterioration following participation in the EVACUATE trial at Monash Medical Centre. She presented with acute right parietal intracerebral haemorrhage and was consented for trial-protocol minimally invasive endoscopic evacuation. Intra-operatively, the surgeon encountered technical difficulties with the trial endoscope (poor visualization, suboptimal clot aspiration, frequent mirror cleaning) and likely entered the ventricular system. Post-operative imaging showed new intraventricular haemorrhage and hydrocephalus requiring external ventricular drain insertion. Despite appropriate management, Dorothy subsequently developed a new contralateral spontaneous intracerebral haemorrhage with very poor prognosis and died 9 days post-operatively. The coroner found the neurosurgical team acted reasonably and appropriately, the surgery did not cause her death, and her death could not have been prevented. However, the coroner criticized Monash Health for failing to assign an Incident Severity Rating (ISR) to this adverse patient safety event, recommending better education about distinction between death audit and adverse event reporting.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes. Report an inaccuracy.
Specialties
Clinical conditions
Procedures
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